Learning When to Trust Medical Knowledge: Regression-Safe Routing for Clinical Reasoning

Abstract: Clinical reasoning LLMs need external medical knowledge, but retrieved evidence and reasoning chains can be outdated, poisoned, or hallucinated. Harmful knowledge can cause regression: changing a correct answer into an incorrect one. We construct a medical knowledge-poisoning benchmark covering retrieved evidence and reasoning chains, with seven attack families filtered by a three-judge "subtle-but-wrong" vote and paired clean exams that separate poisoning effects from question difficulty. No fixed knowledge-use strategy is robust across these settings: strong RAG methods trade robustness to poisoned evidence against accuracy when evidence is useful. We formulate knowledge use as per-instance routing and introduce Med-TrustRouter, a lightweight controller that keeps the solver frozen. From leakage-free runtime signals, it estimates each action's expected correctness gain and uncertainty, preserving the base answer unless another action is confidently better. Across seven medical reasoning settings, Med-TrustRouter achieves 78.9 macro and 69.2 worst-case accuracy, matching the strongest competitor on macro accuracy while substantially improving the worst-case floor. Its gains transfer across solvers and evidence judges, unlike a hand-coded router using the same signals. Similar performance across linear, tree, and neural action-value heads suggests that the benefit comes from routing rather than estimator complexity. These results support learning when to trust external knowledge for robust clinical reasoning.